A nurse is caring for a child with spina bifida.
Which intervention is most important?
Monitor for signs of infection.
Encourage mobility.
Provide nutritional support.
Maintain skin integrity.
The Correct Answer is D
Choice A rationale
Monitoring for signs of infection is crucial in children with spina bifida due to the potential for meningitis and urinary tract infections related to neurological deficits and potential openings in the spinal cord. Normal white blood cell count ranges from 4,500 to 11,000 per microliter, and fever, redness, swelling, or purulent drainage would indicate infection.
Choice B rationale
Encouraging mobility is important to promote development and prevent complications like contractures. However, in the immediate postoperative period or with significant neurological impairment, maintaining skin integrity takes precedence to prevent infection and further complications.
Choice C rationale
Providing nutritional support is essential for growth and development in children with spina bifida, who may have feeding difficulties or increased metabolic needs. Adequate nutrition supports overall health, but preventing skin breakdown in areas prone to pressure is a more immediate concern.
Choice D rationale
Maintaining skin integrity is the most important intervention because children with spina bifida often have sensory and motor deficits that make them susceptible to pressure ulcers, especially over bony prominences and the surgical site if a myelomeningocele repair has occurred. Skin breakdown can lead to serious infections and complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Eczema, also known as atopic dermatitis, is a chronic inflammatory skin condition characterized by pruritus (itching), erythema (redness), and scaling. Topical corticosteroids are the first-line treatment due to their potent anti-inflammatory and immunosuppressive properties, which help to reduce the inflammatory response in the skin and alleviate itching.
Choice B rationale
Psoriasis is a chronic autoimmune skin disorder characterized by thickened, scaly plaques. Topical calcineurin inhibitors are used to treat psoriasis by suppressing the activity of T-cells, which are involved in the inflammatory process. The presentation of an itchy rash as the primary finding is less consistent with typical psoriasis.
Choice C rationale
Contact dermatitis is an inflammatory skin reaction resulting from direct contact with an irritant or allergen, often presenting with redness, swelling, and vesicles in addition to itching. While topical antihistamines can help with itching associated with allergic reactions, topical corticosteroids are generally more effective for managing the inflammation in contact dermatitis.
Choice D rationale
Tinea corporis, or ringworm, is a fungal infection of the skin characterized by circular, raised, scaly patches with central clearing. Topical antifungals are the appropriate treatment for tinea infections as they inhibit the growth and reproduction of the dermatophyte fungi causing the infection.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Type 2 diabetes in pediatric patients can sometimes be managed effectively through lifestyle modifications alone, particularly in the early stages. These changes include dietary adjustments to reduce sugar and processed foods, increased physical activity to improve insulin sensitivity, and weight management.
Choice B rationale
Insulin resistance is a key pathophysiological feature of type 2 diabetes. In this condition, the body's cells do not respond effectively to insulin, leading to elevated blood glucose levels as glucose cannot enter the cells for energy. The pancreas initially produces more insulin to compensate, but eventually, it may not be able to keep up.
Choice C rationale
Type 1 diabetes is more commonly diagnosed in younger children and adolescents, often presenting with acute symptoms. It results from the autoimmune destruction of insulin-producing beta cells in the pancreas, leading to an absolute deficiency of insulin.
Choice D rationale
Type 1 diabetes is an autoimmune disease where the body's immune system mistakenly attacks and destroys the pancreatic beta cells that produce insulin. This autoimmune process is often triggered by genetic predisposition and environmental factors but is not directly caused by lifestyle.
Choice E rationale
Obesity is a significant risk factor for the development of type 2 diabetes due to its association with increased insulin resistance. While individuals with type 1 diabetes can also be obese, obesity is not the primary cause of type 1 diabetes.
Choice F rationale
Type 1 diabetes cannot be cured with lifestyle changes alone because it involves the permanent destruction of insulin-producing cells. Individuals with type 1 diabetes require lifelong insulin therapy to survive.
Choice G rationale
Type 1 diabetes cannot be prevented with healthy eating or other lifestyle modifications because it is an autoimmune condition. The onset is not directly linked to dietary habits or physical activity levels.
Choice H rationale
Type 2 diabetes is less common in infants and toddlers and is more frequently diagnosed in older children, adolescents, and adults, often associated with factors like obesity, family history, and sedentary lifestyle.
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